ORIGINAL RESEARCH

published: 12 November 2020

doi: 10.3389/fmed.2020.570614

Identification of COVID-19 Clinical

Phenotypes by Principal Component
Analysis-Based Cluster Analysis
Wenjing Ye 1† , Weiwei Lu 2† , Yanping Tang 3† , Guoxi Chen 4† , Xiaopan Li 5,6† , Chen Ji 7 ,
Min Hou 8 , Guangwang Zeng 3 , Xing Lan 4 , Yaling Wang 4 , Xiaoqin Deng 4 , Yuyang Cai 8*† ,
Hai Huang 4*† and Ling Yang 3*†
1
Department of Respiratory Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,
Edited by: 2
Department of Emergency, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,
Marc Jean Struelens, 3
Department of Geriatrics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,
Université Libre de Bruxelles, Belgium 4
Department of Tuberculosis Ward 2, Wuhan Pulmonary Hospital, Wuhan, China, 5 Center for Disease Control and
Reviewed by: Prevention, Shanghai, China, 6 Fudan University Pudong Institute of Preventive Medicine, Shanghai, China, 7 Warwick Clinical
Aruni Wilson, Trials Unit, Warwick Medical School, Coventry, United Kingdom, 8 School of Public Health, Shanghai Jiao Tong University
Loma Linda University, United States School of Medicine, Shanghai, China
John Hay,
University at Buffalo, United States

*Correspondence:
Background: COVID-19 has been quickly spreading, making it a serious public health
Yuyang Cai threat. It is important to identify phenotypes to predict the severity of disease and design
caiyuyang@sjtu.edu.cn
an individualized treatment.
Hai Huang
1220775601@qq.com Methods: We collected data from 213 COVID-19 patients in Wuhan Pulmonary Hospital
Ling Yang
yangling01@xinhuamed.com.cn
from January 1 to March 30, 2020. Principal component analysis (PCA) and cluster
analysis were used to classify patients.
† These authors have contributed
equally to this work Results: We identified three distinct subgroups of COVID-19. Cluster 1 was the largest
group (52.6%) and characterized by oldest age, lowest cellular immune function, and
Specialty section:
albumin levels. 38.5% of subjects were grouped into Cluster 2. Most of the lab results in
This article was submitted to
Infectious Diseases - Surveillance, Cluster 2 fell between those of Clusters 1 and 3. Cluster 3 was the smallest cluster (8.9%),
Prevention and Treatment, characterized by youngest age and highest cellular immune function. The incidence of
a section of the journal
Frontiers in Medicine respiratory failure, acute respiratory distress syndrome (ARDS), heart failure, and usage
Received: 08 June 2020
of non-invasive mechanical ventilation in Cluster 1 was significantly higher than others (P
Accepted: 13 October 2020 < 0.05). Cluster 1 had the highest death rate of 30.4% (P = 0.005). Although there were
Published: 12 November 2020
significant differences in age between Clusters 2 and 3 (P < 0.001), we found that there
Citation:
was no difference in demand for medical resources.
Ye W, Lu W, Tang Y, Chen G, Li X,
Ji C, Hou M, Zeng G, Lan X, Wang Y, Conclusions: We identified three distinct clusters of the COVID-19 patients. The results
Deng X, Cai Y, Huang H and Yang L
(2020) Identification of COVID-19
show that age alone could not be used to assess a patient’s condition. Specifically,
Clinical Phenotypes by Principal management of albumin, and immune function are important in reducing the severity
Component Analysis-Based Cluster
of disease.
Analysis. Front. Med. 7:570614.
doi: 10.3389/fmed.2020.570614 Keywords: COVID-19, phenotype, treatment, principal component analysis, cluster analysis

Frontiers in Medicine | www.frontiersin.org 1 November 2020 | Volume 7 | Article 570614

Ye et al.
INTRODUCTION
Since December 2019, pneumonia cases with unknown cause
have been reported in Wuhan (1). It has been identified as an
acute respiratory infection caused by a novel coronavirus, later
named COVID-19 by the World Health Organization (2). Since
that time, COVID-19 has been quickly spreading in China and
other countries, making it a serious global public health threat
(3). It is important for health professionals to take coordinated,
timely, and effective actions to help prevent additional cases or
poor health outcomes.
The entire population is generally susceptible to the virus.
Confirmed cases need to be treated in designated hospitals with
effective isolation and protection conditions. Critical cases should
be admitted to the ICU as soon as possible (3). Mechanical
ventilation, blood purification, and extracorporeal membrane
oxygenation (EMCO) should be applied cautiously in severe
COVID-19 patients (2). Beyond these invasive rescue methods,
doctors hope to find ways to prevent disease progress from the
early stage in the clinic.
Cluster analysis is one of the unsupervised learning methods
which has been successfully applied in medical research (4).
Cluster generation involves merging samples into larger clusters
to minimize the within-cluster variations amongst patients and to
maximize the between-cluster variations. Using cluster analysis,
we can take advantage of in-depth phenotyping to reveal unique
patterns of association among phenotypic variables (5), which
may allow health professionals to develop specialized and more
effective therapeutic strategies for the treatment of COVID-
19 patients.
We hypothesized that COVID-19 comprises discrete clusters
of patients with different clinical characteristics associated with
different outcomes. To test this hypothesis, we used cluster
analysis to identify COVID-19 subgroups and then determined
the disease severity among subgroups. We demonstrate that this
unbiased clustering approach could predict the severity of disease
in patients and thus reveal the key variables clinicians could
consider when evaluating patients.
MATERIALS AND METHODS
Study Design and Participants
We conducted a retrospective, single centered and observational
study in Wuhan Pulmonary Hospital, Hubei Province, China (a
COVID-19-designated hospital in the epidemic outbreak) and
collected clinical data from the patients diagnosed with COVID-
19 between January 1 and March 30, 2020. Patients with missing
clinical data were excluded.
The diagnosis and treatment of COVID-19 complied with the
“new coronary pneumonia diagnosis and treatment plan” issued
by the health commission of the People’s Republic of China.
Laboratory diagnosis of COVID-19 was confirmed by viral
nucleic acid test (NAT) using high-throughput sequencing or
real-time reverse-transcriptase–polymerase-chain-reaction (RT-
PCR), which can amplify the open reading frame 1ab (ORF1ab)
and nucleocapsid protein (NP) gene fragments of COVID-19
Frontiers in Medicine | www.frontiersin.org
Identification of COVID-19 Clinical Phenotypes
virus from the sputum, pharyngeal swab, or lower respiratory
tract samples.
The National Health Commission of the People’s Republic of
China affirmed that data collection and analysis of cases and
close contacts are part of ongoing investigations into outbreaks of
public health events and are therefore exempt from the approval
requirements of the institutional review board.
Data Collection
Clinical data include demographic information (gender, age,
comorbidities), laboratory tests (routine blood test, coagulation
test, infection markers, liver and kidney function, and markers
of myocardial injury), and outcomes (survival or death at
hospital discharge).
Statistical Analysis
The main factors with the highest loading in 18 variables
(including all the laboratory tests) were selected using principal
component analysis (PCA) at baseline. K-means cluster analysis
(6), one of the most widely adopted clustering algorithms, was
carried out to classify COVID-19 patients into different groups
using clinical data based on the PCA results.
PCA analysis was performed using the following variables:
D-Dimer, fibrinogen (FIB), activated partial thromboplastin
time (APTT), prothrombin time (PT), c-reactive protein (CRP),
procalcitonin (PCT), white blood cell (WBC), neutrophil count,
lymphocyte count, monocyte count, alanine aminotransferase
(ALT), aspartate aminotransferase (AST), albumin (Alb), helper
T lymphocyte count, cytotoxic T lymphocyte count, creatinine
(Cr), troponin I (TNI), and N-terminal pro-Brain Natriuretic
Peptide (NT-proBNP). In order to select the number of
important principal components, we chose values with an
eigenvalue >1. The Oblimin method was used in the square
rotation. The similarity of data was calculated using the
principal factors that were identified by PCA-transformed data.
Kaiser–Meyer–Olkin (KMO) and the Bartlett’s test of Sphericity
assessed the adaptive validity of PCA analysis. The representative
variables of principal components were chosen based on their
factor loading.
We performed a K-means cluster analysis in this study.
The main steps were as follows: First, the initial cluster center
was selected with the number of K. Second, cluster steps were
repeated until cluster membership stabilized. Third, each point
was assigned to its closest cluster center. Finally, the new cluster
centers were computed.
SPSS version 24.0 (IBM Corp, Armonk, NY) was used for
statistical analysis. Qualitative and quantitative variables were
summarized using mean and standard deviation (SD), median
and inter-quartile range (IQR), and number and percentage,
respectively. Differences between clusters in qualitative variables
were analyzed using the Chi-squared test. Differences in the
quantitative variables were analyzed using the t-test. In the
case of non-normally distributed variables, the non-parametric
Mann–Whitney test was used. A P < 0.05 was considered
statistically significant.
2 November 2020 | Volume 7 | Article 570614
Ye et al. Identification of COVID-19 Clinical Phenotypes

TABLE 1 | Baseline characteristics and laboratory tests of 213 patients.

Characteristics Count (%) or Mean

(SD) or Median
(IQR)

Gender (Male, %) 116 (54.5%)

Age (years) 61.7 (14.7)
D-Dimer (mg/L) 0.5 (0.2–1.7)
FIB (g/L) 4.2 (1.4)
APTT (s) 35.8 (32.5–39.7)
PT (s) 13.1 (12.5–14.3)
WBC (×109 /L) 6.7 (5.1–9.2)
Neutrophil count (×109 /L) 5.0 (3.2–7.6)
Lymphocyte count (×109 /L) 0.9 (0.6–1.5)
Monocyte coun t (×109 /L) 0.4 (0.2)
Alanine aminotransferase (µ/L) 27 (16–41)
FIGURE 1 | Selection of the study patients.
Aspartate aminotransferase (µ/L) 25 (17.5–42)
Albumin (g/L) 36.0 (5.4)
Creatinine (µmol/L) 68 (56–83)
RESULTS Helper T lymphocyte count (n/µl) 258.3 (23.1–525.6)
Cytotoxic T lymphocyte count (n/µl) 145.4 (72.9–313.0)
Demographics and Baseline CRP (mg/L) 32.4 (3.4–81.7)
Characteristics of Patients With COVID-19 PCT (ng/ml) 0.0 (0.0–0.1)
There were 431 confirmed COVID-19 patients admitted to TNI (ng/ml) 0.0 (0.0–0.0)
Wuhan Pulmonary Hospital between January 1 and March NT-proBNP (pg/ml) 144 (34–558)
30, 2020 and 218 (52.8%) were excluded due to missing Death (n, %) 46 (21.6%)
clinical data (Figure 1). Two hundred and thirteen patients were Ventilator (n, %) Invasive mechanical ventilation 33 (15.5%)
ultimately enrolled with a mean age of 61.85 ± 14.72 years, Non-invasive mechanical ventilation 49 (23%)
and 116 (54.50%) of them were males. 167 (78.40%) patients Comorbidity (n, %) Respiratory failure 37 (17.4%)
survived, while 46 (21.60%) died. Demographic characteristics, ARDS 34 (16%)
laboratory tests, and comorbidities of all patients are shown Heart failure 50 (23.5%)
in Table 1. AKI 12 (5.6%)
Diabetes mellitus 42 (19.7%)
Principal Component Analysis and Cluster
ARDS, acute respiratory dyspnea syndrome; AKI, acute kidney injury; CRP, C-reactive
Analysis for the Identification of COVID-19 protein; PCT, procalcitonin; NT-proBNP, N-terminal pro brain natriuretic peptide; TNI,
Clusters troponinI; FIB, fibrinogen; APTT, anginal partial thromboplastin time; PT, prothrombin time;
WBC, white blood cell.
The KMO value was 0.676, and the p-value of Bartlett’s
test of sphericity was <0.001. Six components were
retained using the PCA analysis. These six components
significantly contributed to explaining the relationships the highest CRP and neutrophil count, the lowest lymphocyte
among the 18 variables and accounted for 73.18% of the count and cellular immune function and albumin level, and the
information. The following representative variables were highest NT-proBNP.
chosen based on relatively high factor loading: factor 1, 38.5% of subjects (n = 82) were grouped into Cluster
CRP and neutrophil counts; factor 2, WBC and monocyte 2. This cluster had the middle age with mean age of 54.1
counts; factor 3, ALT and AST; factor 4, PCT and Fib; factor ± 5.8 years. NT-proBNP, cytotoxic T lymphocyte count,
5, TNI and D-Dimer; and factor 6, Alb and NT-proBNP helper T lymphocyte count, AST, and lymphocyte count fell
(Table 2). between those of Clusters 1 and 3. CRP, Alb, and D-Dimer
of Cluster 2 had a significant difference between Cluster
Baseline Characteristics of COVID-19 1. Clusters 2 was characterized by middle age and general
Clusters basic situation.
Three distinct subgroups were identified using the cluster Cluster 3 was the smallest cluster (n = 19; 8.9% of subjects).
analysis (Table 3). Differences between Clusters 2 and 3 are It was characterized by youngest age with mean (SD) age of 31.4
shown in Supplementary Table 1. (12.2) years and highest cytotoxic T lymphocyte count.
In total, 52.6% of subjects (n = 112) were grouped into Cluster There was no significant difference in fibrinogen, activated
1. This cluster was characterized by the oldest age with mean age APTT, PT, WBC, monocyte count, ALT, creatinine, and PCT
of 72.7 ± 6.7 years, most obvious inflammatory reaction with among the three clusters.

Frontiers in Medicine | www.frontiersin.org 3 November 2020 | Volume 7 | Article 570614

Ye et al. Identification of COVID-19 Clinical Phenotypes

TABLE 2 | Correlations of the 18 original variables with the six main factors derived from the principal component analysis.

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6

Eigenvalue 4.388 2.539 1.673 1.629 1.136 1.076

% variance explained 25.812 14.934 9.840 9.581 6.683 6.328
APTT 0.139 0.304 0.409 −0.751 −0.119 0.077
PT 0.197 0.280 0.201 −0.815 −0.113 −0.130
WBC 0.423 0.743 −0.154 0.203 −0.315 −0.043
Monocyte count −0.254 0.646 0.033 0.242 −0.285 −0.309
Lymphocyte count −0.696 0.514 0.261 0.028 0.058 0.072
Neutrophil count 0.603 0.592 −0.196 0.175 −0.293 −0.046
Alb −0.707 0.068 0.146 0.018 0.017 0.174
CRP 0.747 0.014 0.232 −0.012 −0.212 0.310
ALT 0.232 −0.098 0.709 0.315 0.099 −0.369
AST 0.485 −0.047 0.705 0.218 0.295 −0.119
Cr 0.275 0.038 0.003 −0.082 0.257 −0.288
TNI 0.401 0.418 −0.084 −0.009 0.416 −0.146
PCT 0.379 0.139 0.313 0.232 0.029 0.712
Helper T lymphocyte count −0.768 0.418 0.174 0.080 0.147 0.075
Cytotoxic T lymphocyte count −0.761 0.425 0.182 0.105 0.039 0.065
NT-proBNP 0.473 0.368 −0.105 0.039 0.295 0.186
Fib 0.283 −0.223 0.201 0.205 −0.511 −0.130
D-Dimer 0.426 0.323 −0.282 −0.002 0.517 −0.021

CRP, C-reactive protein; PCT, procalcitonin; NT-pro BNP, N-terminal pro brain natriuretic peptide; TNI, troponinI; FIb, fibrinogen; APTT, anginal partial thromboplastin time; PT, prothrombin
time; WBC, white blood cell; Cr, creatinine; Alb, albumin; ALT, Alanine aminotransferase; AST, Aspartate aminotransferase.

TABLE 3 | Baseline characteristics of three clusters.

Cluster 1 (n = 112) Cluster 2 (n = 82) Cluster 3 (n = 19) P

Gender (Male, %) 63 (56.3%) 43 (52.4%) 10 (52.6) 0.620

Age (years) 72.7 (6.7) 54.1 (5.8) 31.4 (12.2) <0.001
D-Dimer (mg/L) 0.9 (0.4–3.5) 0.3 (0.2–0.6) 0.3 (0.1–0.6) <0.001
FIB (g/L) 4.1 (1.4) 4.3 (1.6) 4.1 (1.2) 0.773
APTT (s) 36.3 (23.6–40.6) 34.5 (31.8–37.2) 35.6 (33.4–41.8) 0.082
PT (s) 13.2 (12.5–14.4) 13.0 (12.4–13.9) 12.9 (12.5–13.7) 0.220
WBC (×109 /L) 6.7 (5.2–9.3) 6.8 (4.8–9.3) 6.3 (5.2–9.1) 0.771
Neutrophil count (×109 /L) 5.1 (3.7–8.0) 5.0 (3.0–7.8) 3.7 (2.8–4.9) 0.029
Lymphocyte count (×109 /L) 0.8 (0.5–1.3) 1.0 (0.6–1.7) 1.5 (0.9–2.3) 0.001
Monocyte count (×109 /L) 0.4 (0.2) 0.4 (0.2) 0.4 (0.1) 0.293
Alanine aminotransferase (µ/L) 26.5 (16.3–43.8) 28.5 (17–40.5) 19 (11–32) 0.16
Aspartate aminotransferase (µ/L) 29 (20–44.8) 23.5 (16–40.2) 19 (14–32) 0.009
Albumin (g/L) 34.8 (5.2) 37.3 (5.1) 37.9 (6.6) 0.002
Creatinine (µmol/L) 70 (58–89) 66.5 (53.8–78) 73 (52–78) 0.205
Helper T lymphocyte count (n/µl) 237.0 (85.2–422.5) 262.4 (142.7–652.7) 366.0 (274.4–696.8) 0.003
Cytotoxic T lymphocyte count (n/µl) 115.4 (51.0–239.8) 189.9 (97.8–387.8) 316.4 (164.3–498.8) <0.001
CRP (mg/L) 44.4 (15.0–85.1) 22.6 (1.0–83.0) 19.5 (1.0–31) 0.002
PCT (ng/ml) 0.0 (0.0–0.1) 0.0 (0.0–0.1) 0.0 (0.0–0.1) 0.065
TNI (ng/ml) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.015
NT-proBNP (pg/ml) 390 (94.8–875.6) 48.5 (15–188) 15 (15–292) <0.001

CRP, C-reactive protein; PCT, procalcitonin; NT-pro BNP, N-terminal pro brain natriuretic peptide; TNI, troponinI; FIB, fibrinogen; APTT, anginal partial thromboplastin time; PT, prothrombin
time; WBC, white blood cell.

Frontiers in Medicine | www.frontiersin.org 4 November 2020 | Volume 7 | Article 570614

Ye et al.
TABLE 4 | Disease severity of three clusters.
Cluster 1 (n = 112)
Invasive mechanical ventilation 22 (19.6%)
Non-invasive mechanical ventilation 31 (27.7%)
Respiratory failure 30 (26.8%)
ARDS 24 (21.4%)
Heart failure 36 (32.6%)
AKI 9 (8%)
Death 34 (30.4%)
ARDS, acute respiratory dyspnea syndrome; AKI, acute kidney injury.
COVID-19 Clusters and Disease Severity
The disease severity of COVID-19 in the current patient
population was compared across the clusters (Table 4).
Differences between Clusters 2 and 3 are shown in
Supplementary Table 2. The incidence of respiratory failure,
acute respiratory distress syndrome (ARDS), and heart failure in
Cluster 1 was significantly higher than the other two clusters (P
< 0.05). The proportion of non-invasive mechanical ventilation
usage in Cluster 1 was 27.7%, which was significantly higher than
other clusters (P = 0.017). Cluster 1 also had the highest death
rate of 30.4% (P = 0.005).
DISCUSSION
COVID-19 is a novel, rapidly spreading, viral illness that
represents an emergent global health threat. Mortality rate is
higher in elderly and intensive care unit (ICU) COVID-19
patients, reaching 17–38% in recent reports (7, 8). Progressive
lymphocytopenia was often found in severe cases (9–11). In
this study, we identified three distinct subgroups of COVID-
19 through a cluster analysis of 213 patients. Cluster 1 was
characterized by oldest age, highest mortality rate (30.36%), and
significantly lower lymphocyte count. This result was consistent
with previous reports (7, 8).
The immune system of a host controls invading pathogens and
thereby determines the prognosis of patients with any infectious
disease, including pneumonia (12). As immune deficiency is
closely tied to mortality, evaluating the immune condition could
be an important companion to monitoring a patient’s general
condition in order to estimate prognosis (13). We found that
helper T lymphocyte count and cytotoxic T lymphocyte count
in Cluster 1 were significantly lower than those of the other two
clusters. This suggested more impaired immune function in the
Cluster 1 patients. Treating the immune deficiency at the early
stage of disease may reduce the risk of disease deterioration and
improve patient prognosis. Therefore, more attention to immune
function is required in the elderly, severely ill patients instead of
focusing on invasive treatment only.
Low albumin can lead to hypoproteinemia, and it can cause
a range of diseases, such as serous effusion, pulmonary edema,
heart failure, and more. Timely correction of hypoproteinemia
could effectively prevent the incidence of complications (14).
Therefore we compared the albumin differences between three
clusters. Albumin of Cluster 1 was significantly lower than the
Frontiers in Medicine | www.frontiersin.org
Identification of COVID-19 Clinical Phenotypes
Cluster 2 (n = 82) Cluster 3 (n = 19) P
10 (12.2%) 1 (5.3%) 0.056
18 (22%) 0 (0%) 0.017
6 (7.3%) 1 (5.3%) <0.001
9 (11%) 1 (5.3%) 0.019
13 (15.9%) 1 (5.3%) <0.001
3 (3.7%) 0 (0%) 0.087
9 (11%) 3 (15.8%) 0.005
other two clusters in our study. Therefore, it is also important to
pay attention to the albumin level in elderly patients.
Our cluster analysis suggests that immunological parameters
(helper T lymphocyte count and cytotoxic T lymphocyte count)
and serum albumin level are important in determining prognosis
and the vulnerability to developing comorbidities, including
respiratory failure, ARDS, and heart failure. Improving the
immune status and albumin level of patients may be a potential
measures to prevent disease progression.
The mortality rate was higher in elderly patients (7, 8).
We found that the mortality rate of Cluster 3, which was
characterized by the youngest mean age, was not significantly
different from middle-aged patients who grouped in Cluster
2. This result aroused our attention. In previous studies, it
was mentioned that some COVID-19 patients showed immune
imbalance and a cytokine storm, which could be responsible
for further lung injury (15–17). Young patients in Cluster 3
had the highest T lymphocyte count, and most likely had a
cytokine storm. Thus, is the implication to clinicians that if a
younger patient presents with COVID-19, they should check T
lymphocyte counts because those with very high levels may be
at risk of developing severe disease despite a younger age. This
needs further pathological research to validate.
D-Dimer is a degradation product that is produced in
hydrolysis of fibrin (18). Studies have reported increase in D-
Dimer levels in patients with pneumonia, has an indication of
the presence of thrombosis and the blood hypercoagulable state
(19, 20). High D-Dimer is likely to be associated with persistent
clotting disorders, microthrombotic formation, pulmonary
embolism and acute myocardial infarction in long-stay patients
or death patients, which may cause refractory hypoxemia,
respiratory failure, disseminated intravascular coagulation or
even death. Our previous study found that COVID-19 patients
with higher initial and peak D-Dimer value tended to have a
higher risk of death (21). In this study, we found that D-Dimer
of Cluster 1 was significantly higher than other two clusters.
Cluster 1 also had the highest death rate of 30.4%, which was
consistent with previous studies. These patients were likely to
have myocardial infarction and/or pulmonary embolism, and it
might also explain the difference of myocardial enzymes (TNI
and AST) among the three clusters. This might suggest the
importance of early anticoagulant intervention.
Neutrophil count and lymphocyte count were found to have
great prognostic power in community-acquired pneumonia. The
5 November 2020 | Volume 7 | Article 570614
Ye et al.
increase of neutrophils often indicates that the patients have
bacterial infection and the infection is aggravated. The decrease
of lymphocyte means that the immune function is poor (22, 23).
At the early stage of COVID-19, the total number of leukocytes
is normal or decreases, while the lymphocyte count decreases
(3). We found that Cluster 1 had the lowest lymphocyte count
and the highest neutrophil count. There was no difference in
Neutrophil count and lymphocyte count between Cluster 2 and
3. Our previous study found that COVID-19 patients with
high neutrophil-lymphocyte Count Ratio might have a poor
prognosis, even a risk of death (21). Those might suggest that the
aggravated condition and the infection is difficult to control in
Cluster 1.
According to our clustering results in disease severity, patients
in Cluster 1 had a high incidence of respiratory failure, ARDS,
heart failure, and high utilization rate of non-invasive mechanical
ventilation. The demand for medical resources of these patients
is significantly higher than other clusters. Thus, we suggest
that Cluster 1 needs a comprehensive treatment plan, or may
even need to stay in the intensive care unit. Although there
were significant differences in age between Clusters 2 and
3, we also found that there was no significant difference in
demand for medical resources between these two clusters. It
could be interpreted that doctors should pay the same clinical
attention to middle-aged and young patients. Age alone could
not be used to assess a patient’s condition, we must correct the
misunderstanding that young patients should always be assumed
to have relatively mild disease in COVID-19.
There are some potential limitations in our study. First, this
was a single center retrospective study. All of the data were
collected from patients in Wuhan Pulmonary Hospital. Most of
the patients in this hospital were symptomatic, severe or even
critical. As a result, the proportion of young and mild disease
patients in the study was relatively low. Second, only 213 out of
413 patients were enrolled in our study. The exclusion of patients
with missing clinical data might cause some bias in our analysis.
Our results could be more representative if we are able to collect
these data in the future. Finally, our data may be subjected to
recall bias and selection bias due to the nature of our study.
For example, the record of patients’ comorbidities might not be
accurate and complete, considering the unprecedented pressure
during admission and treatment.
Further studies with more detailed and representative data are
needed. In particular, a long-term follow up of the patients will
allow us to further explore the differences between phenotypes.
CONCLUSIONS
We identified three distinct subclasses of COVID-19 patients in
Wuhan Pulmonary Hospital. It might be necessary to improve
REFERENCES
1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus
from patients with pneumonia in China, 2019. N Engl J Med. (2020) 382:727–
33. doi: 10.1056/NEJMoa2001017
2. Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World
Health Organization declares global emergency: a review of the 2019 novel
Frontiers in Medicine | www.frontiersin.org
Identification of COVID-19 Clinical Phenotypes
the immune function and pay attention to the underlying
health conditions in the elderly patients. D-Dimer, lymphocyte
count, neutrophil count, NT-proBNP, T lymphocyte count,
and serum albumin should be paid attention to. This might
remind us that correction of these abnormal lab results in time
can be useful in preventing the corresponding complications
and reducing the mortality rate. Age alone could not be
used to assess a patient’s condition; cluster assessment may be
more reliable.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/Supplementary Materials, further inquiries can be
directed to the corresponding author/s.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by The National Health Commission of
the People’s Republic of China. Written informed consent
for participation was not required for this study in
accordance with the national legislation and the institutional
requirements. Written informed consent was not obtained
from the individual(s) for the publication of any potentially
identifiable images or data included in this article. Informed
consent was exempted with the approval of Medical Ethics
Committee of Xinhua Hospital Affiliated to Shanghai
Jiaotong University School of Medicine, Shanghai, China
(No. XHEC-D-2020-052).
AUTHOR CONTRIBUTIONS
YC, HH, and LY designed the current study and revised the
manuscript. YT, GC, XLi, CJ, MH, GZ, XLa, YW, and XD
collected data. WY and WL wrote the manuscript and revised the
manuscript. All authors contributed to the article and approved
the submitted version.
FUNDING
This work was supported by Zhejiang University special scientific
research fund for COVID-19 prevention and control [grant
number 2020XGZX065].
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fmed.
2020.570614/full#supplementary-material
coronavirus (COVID-19). Int J Surg. (2020) 76:71–6. doi: 10.1016/j.ijsu.2020.
02.034
3. Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A
rapid advice guideline for the diagnosis and treatment of 2019
novel coronavirus (2019-nCoV) infected pneumonia (standard
version). Mil Med Res. (2020) 7:4. doi: 10.1186/s40779-020-
0233-6
6 November 2020 | Volume 7 | Article 570614
Ye et al.
4. Tzeng CR, Chang YC, Chang YC, Wang CW, Chen CH, Hsu MI. Cluster
analysis of cardiovascular and metabolic risk factors in women of reproductive
age. Fertil Steril. (2014) 101:1404–10. doi: 10.1016/j.fertnstert.2014.
01.023
5. Ahmad T, Pencina MJ, Schulte PJ, O’Brien E, Whellan DJ, Piña IL, et al.
Clinical implications of chronic heart failure phenotypes defined by cluster
analysis. J Am Coll Cardiol. (2014) 64:1765–74. doi: 10.1016/j.jacc.2014.
07.979
6. Sd C, Commandeur JJ, Frank LE, Heiser WJ. Effects of group size and lack of
sphericity on the recovery of clusters in K-means cluster analysis. Multivariate
Behav Res. (2006) 41:127–45. doi: 10.1207/s15327906mbr4102_2
7. Wang D, Hu B, Hu C, Zhu FF, Liu X, Zhang J, et al. Clinical characteristics of
138 hospitalized patients with 2019. Novel Coronavirus-Infected Pneumonia
in Wuhan, China. JAMA. (2020) 323:1061–9. doi: 10.1001/jama.202
0.1585
8. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological
and clinical characteristics of 99 cases of 2019 novel coronavirus
pneumonia in Wuhan, China: a descriptive study. Lancet. (2020)
395:507–13. doi: 10.1016/S0140-6736(20)30211-7
9. Li G, Fan Y, Lai Y, Han TT, Li ZH, Zhou PW, et al. Coronavirus infections and
immune responses. J Med Virol. (2020) 92:424–32. doi: 10.1002/jmv.25685
10. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of
patients infected with 2019 novel coronavirus in Wuhan, China. Lancet.
(2020) 395:497–506. doi: 10.1016/S0140-6736(20)30183-5
11. Han Q, Lin Q, Jin S, You L. Coronavirus 2019-nCoV: a brief perspective from
the front line. J Infect. (2020) 80:373–7. doi: 10.1016/j.jinf.2020.02.010
12. Lee KY. Pneumonia, acute respiratory distress syndrome, and early immune-
modulator therapy. Int J Mol Sci. (2017) 18:388. doi: 10.3390/ijms180
20388
13. Guo L, Wei D, Zhang X, Wu Y, Li Q, Zhou M, et al. Clinical features predicting
mortality risk in patients with viral pneumonia: the MuLBSTA score. Front
Microbiol. (2019) 10:2752. doi: 10.3389/fmicb.2019.02752
14. Senoo T, Ishida S, Ohta K, Inaba Y, Takagi M, Yoshioka H, et al.
Hypoproteinemia as an precipitating factor of congestive heart failure in
hypertensive heart disease (author’s transl). Nihon Ronen Igakkai Zasshi.
(1980) 17:527–32. doi: 10.3143/geriatrics.17.527
15. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al.
COVID-19: consider cytokine storm syndromes and immunosuppression.
Lancet. (2020) 395:1033–4. doi: 10.1016/S0140-6736(20)30628-0
16. Wu D, Yang XO. TH17 responses in cytokine storm of COVID-19: an
emerging target of JAK2 inhibitor Fedratinib. J Microbiol Immunol Infect.
(2020) 53:368–70. doi: 10.1016/j.jmii.2020.03.005
Frontiers in Medicine | www.frontiersin.org
Identification of COVID-19 Clinical Phenotypes
17. Zhang Y, Fan L, Xi R, Mao Z, Shi D, Ding D, et al. Lethal concentration
of perfluoroisobutylene induces acute lung injury in mice mediated via
cytokine storm, oxidative stress and apoptosis. Inhal Toxicol. (2017) 29:255–
65. doi: 10.1080/08958378.2017.1357772
18. Gorjipour F, Totonchi Z, Gholampour Dehaki M, Hosseini S, Tirgarfakheri
K, Mehrabanian M, et al. Serum levels of interleukin-6, interleukin-8,
interleukin-10, and tumor necrosis factor-α, renal function biochemical
parameters and clinical outcomes in pediatric cardiopulmonary bypass
surgery. Perfusion. (2019) 34:651–9. doi: 10.1177/0267659119842470
19. Guo SC, Xu CW, Liu YQ, Wang JF, Zheng ZW. Changes in plasma
levels of thrombomodulin and D-dimer in children with different types of
Mycoplasma pneumoniae pneumonia. Zhongguo Dang Dai Er Ke Za Zhi.
(2013) 15:619–22.
20. Inoue Arita Y, Akutsu K, Yamamoto T, Kawanaka H, Kitamura M, Murata H,
et al. A fever in acute aortic dissection is caused by endogenous mediators that
influence the extrinsic coagulation pathway and do not elevate procalcitonin.
Intern Med. (2016) 55:1845–52. doi: 10.2169/internalmedicine.5
5.5924
21. Ye W, Chen G, Li X, Lan X, Ji C, Hou M, et al. Dynamic changes of D-
dimer and neutrophil-lymphocyte count ratio as prognostic biomarkers
in COVID-19. Respir Res. (2020) 21:169. doi: 10.1186/s12931-020-
01428-7
22. Celikbilek M, Dogan S, Ozbakir O, Zararsiz G, Kücük H, Gürsoy S,
et al. Neutrophil-lymphocyte ratio as a predictor of disease severity in
ulcerative colitis. J Clin Lab Anal. (2013) 27:72–6. doi: 10.1002/jcla.
21564
23. Huang H, Wan X, Bai Y, Bian J, Xiong J, Xu Y, et al. Preoperative neutrophil-
lymphocyte and platelet-lymphocyte ratios as independent predictors of T
stages in hilar cholangiocarcinoma. Cancer Manag Res. (2019) 11:5157–
5162. doi: 10.2147/CMAR.S192532
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Ye, Lu, Tang, Chen, Li, Ji, Hou, Zeng, Lan, Wang, Deng,
Cai, Huang and Yang. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (CC BY). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) and the
copyright owner(s) are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
7 November 2020 | Volume 7 | Article 570614